Patriot GoTravel℠ America

Why Consider International Travel Medical Insurance?

Traveling abroad can be an exciting experience. But what would happen if you or one of your family members became ill or injured while away from home? International travel can quickly turn frightening if you’re not prepared for a medical emergency.

Most travelers assume they will be covered by their standard medical plan. The truth is, while traditional plans may offer adequate domestic coverage, they are not designed for international travel. Without even realizing it, you may be putting your health - and that of your family - at risk.

You have enough to worry about when you’re traveling. Don’t let your medical coverage be an uncertainty. International Medical Group® (IMG®) has developed Patriot GoTravelSM plans to provide you and your family Coverage Without Boundaries® so you can spend more time enjoying your international experience, and less time worrying about your medical coverage.

Why Patriot GoTravelSM
America

Patriot GoTravelSM
America
plan offers a complete package of international benefits available 24 hours a day.
Patriot GoTravelSM America provides coverage for non-U.S. citizens traveling outside their home country.
The plan is available for a minimum of 10 days up to a maximum of two years, in accordance with the terms of the Certificate of Insurance.

Additionally, the plan offers excellent benefits and services to meet your global travel needs. You have access to international, multilingual customer service centers, claims administrators who process claims from all over the world, handling virtually every language and currency, and 24 hour access to highly qualified coordinators of emergency medical services and international treatment. You can also choose from a wide range of deductibles, several Maximum Limits, and you have access to more than 17,000 providers through our International Provider AccessSM (IPA) when seeking treatment outside the U.S. You can also reduce your out-of-pocket costs when seeking treatment in the U.S. by locating providers through the independent Preferred Provider Organization.

A Unique, Full-Service Approach

We know that the reasons to travel abroad are many and varied - that’s why our services are designed to provide you with the assistance you need no matter where you are. Our goal is to provide you with Coverage Without Boundaries. By providing global products and services to vacationers, those working or living abroad for short or extended periods, people traveling frequently between countries, and those who maintain multiple countries of residence, we are the single resource for all your international travel medical insurance needs.

Our services and support sets us apart. We’ve served more than a million people around the globe - always focused on the specific needs of each individual. We’ve set the benchmark for industry service levels by integrating independent credentialing services with in-house, fully owned and operated service divisions. We’re there with you, wherever you go - bringing support for all your insurance needs around the globe - providing you Global Peace of Mind®.

Plan Information & Highlights

Maximum Limits

$50,000, $100,000, $500,000, $1,000,000

Individual Deductible

$0, $100, $250, $500, $1,000, $2,500

Coinsurance - for treatment received outside the U.S. & Canada

No Coinsurance

Coinsurance - for treatment received within the U.S. & Canada

In the PPO Network - The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Maximum LimitOut of the PPO Network - The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Maximum Limit

Benefit Period

Six months

MyIMGSM

24 hour secure access from anywhere in the world to manage your account at anytime

World-class Medical Benefits

Coverage available for in-patient and out-patient medical expenses

Schedule of Benefits

All coverages, benefits and premium amounts shown on this website are in U.S. dollars.

Medical BenefitsUsual, reasonable and customary charges. Subject to deductible and coinsurance when applicable.

*Available to the primary insured only. Available with a minimum purchase of 3 months of medical and AD&D rider coverage. Premium is charged in whole month increments.

All premium rates are effective through 4/1/2013. Rates include surplus lines tax where applicable. A dependent child is your child shown on the Application Form over 14 days and under 18 years of age, traveling with you, and for whom premium has been paid. The maximum amount of coverage for applicants who are 80 years of age or older is $10,000.

Conditions of Coverage

Coverage and benefits are subject to the deductible and coinsurance, and all terms of the certificate of coverage and Master Policy.

Coverage under a Patriot GoTravel plan is secondary to any other coverage.

Coverage and benefits are for medically necessary, usual, reasonable and customary charges only.

Charges must be administered or ordered by a physician.

Charges must be incurred during the Period of Coverage or the Benefit Period.

Claims must be presented for payment within the Period of Coverage, Benefit Period or during the three months immediately following the Period of Coverage.

Eligibility

The following conditions apply to all persons applying for and/or enrolling in Patriot GoTravel.

Patriot GoTravel is travel insurance for U.S. citizens traveling outside the United States with coverage for brief returns to the U.S., and for non-U.S. citizens traveling outside their home country

For those under 65 years of age and visiting the U.S., your initial Period of Coverage must begin within six months of arrival in the U.S. For those 65 years of age and older, it must begin within 30 days of arrival. These requirements will be waived with proof of previous valid international travel insurance. Prior U.S. domestic health care coverage does not meet this eligibility requirement. Please provide the name of your international insurance carrier on the Application Form. If you are not in the U.S. at the time of application, please indicate your expected date of arrival on your Application Form.

Renewal of Coverage

If your Patriot GoTravel plan is purchased for a minimum of one month, coverage may be renewed (unless there is a break in coverage) for a total of up to two years. Renewals are available in whole month or daily increments and may be completed online or by using a paper application, however, renewals of less than one month are available only online. For each renewal of less than one month com-pleted online, you will be charged an additional $5 processing fee. Each insured person must only satisfy one deductible and coinsur-ance within each 12 month coverage period. Please note: Renewal rates may differ from initial rates.

Eligibility to purchase, extend or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including the Patient Protection and Affordable Care Act (PPACA).

Quality Guarantee

Your satisfaction is very important. If you are not pleased with this product for any reason, you may submit a written request, prior to your effect date for cancellation and refund of your premium. If you do not have any claims filed , you may cancel your plan after your effective date, however, the following conditions will apply: 1) you will be required to pay a $50 cancellation fee and 2) only full month premiums will be considered for refunds (e.g., if you choose to cancel your coverage two months and two weeks prior to the date your coverage ends, the administrator will only consider the two full months for a refund). If you have filed claims, your premium is non-refundable.

Enrollment Process & Application Form

You should read the following important information prior to completing the Application Form.

How to Enroll

Before you begin your travel, simply fill out the Application Form and calculate the premium for the time period you and/or your family will be traveling. Once you have completed the Application Form, return it to us.

You, your spouse and unmarried dependent children (over 14 days and under 18 years of age) listed on the Application Form and for whom premiums have been paid will be covered from the latest of the following dates:

The date the administartor receives your completed Application Form and the appropriate premium;

the date you depart from your home country; or

the date requested on your Application Form.

Patriot GoTravel coverage ends on the earliest of the following dates:

The end of the period for which premium has been paid;

the date requested on your Application Form; or

the date you return to your home country (however, see Home Country Coverage below).

Enrollment Processing & Fulfillment Kits

The administrator normally processes Application Forms within 24 hours of receipt. Once processing is complete, the administrator will mail a fulfillment kit to the mailing address listed on the application form. The fulfillment kit will include an Identification Card, contact numbers, claim forms and your insurance certificate providing a complete description of your coverage under the contract. Please note: If you require express mail delivery, there is an additional charge listed on the Application Form.

Online Fulfillment Kit

For convenience, approved applicants may choose to communicate electronically and download their fulfillment kit from the website for immediate access. To do this, you must check the appropriate box listed in Section 2 of the application form. We must have your correct email address to complete this process. If the administrator has processed and approved your application form, you will receive an email that contains all of the hyperlinks to easily obtain the fulfillment information through the Internet.

Claims Procedure

Precertification

Each proposed hospital admission, in-patient or out-patient surgery, and other procedures as noted in the Certificate of Insurance must be Precertified for medical necessity, which means the insured person or their attending physician must communicate with a representative at the number listed on the identification card prior to admission to a hospital or performance of a surgery. In case of an emergency admission, the Precertification call must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not Precertified, eligible claims and expenses will be reduced by 50%. It is important to note that Precertification is only a determination of medical necessity, not an assurance of coverage, veri-fication of benefits or a guarantee of payment. All medical expenses eligible for reimbursement must be medically necessary and will be paid or reimbursed at usual, reasonable, and customary rates. Please refer to the Certificate of Insurance for full details of the Precertification requirements.

For Precertification please call: In the U.S.: 1.800.628.4664 (toll free) or 1.317.655.4500. Outside the U.S.: 001.317.655.4500 (collect if necessary). This information will also be provided on your ID card.

Note: An insured person may begin the Precertification process through Client Center of our website. Simply look for the Precertification option. You will be asked to provide the required information, which can then be submitted electronically. Once we have confirmed receipt of your request, our utilization management and review team will review the information provided and respond to the insured person or the provider within 2 business days. Please note that this online service will only initiate the Precertification process, and it should not be used to Precertify emergency admissions, procedures, or evacuations.

Claim Payment

All benefits payable under Patriot GoTravel are subject to the terms and conditions in the Certificate of Insurance. To make claim processing efficient, claims may be paid in two ways.

Eligible expenses that have been paid by or on behalf of theinsured person may be reimbursed by check directly to theinsured person.

Eligible expenses that have not yet been paid by the insuredperson may, at the option of IMG, be paid either to the insured person or directly to the provider.

Claim forms can be accessed here and mailed to International Medical Group, P.O. Box 88500, Indianapolis, IN 46208- 0500 USA. All claims administrator contact numbers, claim forms and the Certificate of Insurance are included in the fulfillment kit.

Summary of Benefits

The following is a summary of benefits and terms that are available to eligible insureds on the Patriot GoTravel plans.

Deductible

On the Application Form, you will be asked to circle your choice of a deductible. Your premium rate is dependent on the deductible you choose. Please see the Application Form for more information.

Emergency Room

Charges incurred for the use of the Emergency Room due to an accident or illness are covered up to the Maximum Limit.

Charges incurred for the use of the Emergency Room for treatment of an illness are subject to an additional (extra) $250 deductible if treatment does not require admission to the hospital.

Sudden and Unexpected Recurrence of a Pre-Existing Condition

(Non-U.S. citizens only) For those under age 65, Patriot GoTravel America will pay up to a $50,000 lifetime maximum for eligible medical expenses. For those age 65 and older, Patriot GoTravel America will pay up to $2,500 lifetime maximum.

Hospital Daily Indemnity

Each plan pays $100 directly to the insured person for each night of a required overnight stay in a hospital up to a maximum of 10 days. The hospital stay must be covered under this plan in order to receive this benefit. This benefit is not available for Patriot GoTravel America (non-U.S. citizens) if the hospitalization is due to the Sudden Recurrence of a Pre-existing Condition.

Benefit Period

If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the six-month Benefit Period may offer continued coverage for that injury or illness. When the Certificate expires, the Company will review the date of initial treatment for the covered injury or illness. If treatment began less than six months before the Period of Coverage expired, benefits for the covered injury or illness continues. This is subject to the Maximum Limits and the other terms of the plan until there have been six months of continuous coverage for the covered injury or illness.

Incidental Home Country Coverage

During the Period of Coverage an insured person may return to their home country for incidental visits up to a cumulative two weeks total, subject to: 1. The insured person must have left their home country, 2. The total Period of Coverage must be for a minimum of 30 days, and 3. The return to the home country may not be taken to receive treatment for an illness or injury incurred while traveling.

End of Trip Home Country Coverage

For every five months of continuous coverage you purchase, you can purchase one additional month of home country coverage as an accommodation and supplemental travel benefit, up to a maximum of two months. To purchase this special home country extension coverage, please calculate your premium on the Application Form to include the additional month(s).

Sports and Activities Coverage

Patriot GoTravelSM
America
covers injuries incurred during athletic activities which are non-organized, non-contact and engaged in by the insured person solely for leisure, recreation, entertainment or fitness purposes. Some of these sports and activities include, but are not limited to, motor cycle/motorscooter riding, recreational downhill and/or cross country snow skiing, horseback riding, sub-aquatic activities (to 10m), wakeboarding, and water skiing. However, activities not covered include amateur or professional sports or other athletic activity which is organized and/or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or government body), or the International Olympic Committee, and or Adventure Sports. Please note this is only a summary of sports and activities and exclusions. For additional information, please refer to the Certificate of Insurance.

Accidental Death And Dismemberment

Patriot GoTravelSM
America
offers a $25,000 principal sum benefit for Accidental Death and Dismemberment occurring during the Period of Coverage: • Accidental Loss of life - principal sum • Accidental Loss of two Members - principal sum • Accidental Loss of one Member - 50% of principal sum. "Member" means hand, foot or eye.

Common Carrier Accidental Death

If accidental death should occur while traveling on a commercial Common Carrier, $50,000 is payable to the designated beneficiary, to a maximum of $250,000 per family.

Natural Disaster

This benefit is available in the event an insured person is required to depart his/her destination due to an evacuation order issued by prevailing authorities in connection with a Natural Disaster. Natural Disaster is defined as widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event resulting in migration of the population for its safety.

Trip Interruption

If, during a covered trip, there is an unexpected death of an immediate family member (spouse, child, parent or sibling), a break-in at the insured’s principle residence, or the substantial destruction of the insured’s principal residence due to a fire or natural disaster, Patriot GoTravelSM
America
pays to return the insured to the area of principal residence. The plan pays for a one way air or ground trans-portation ticket of the same class as the unused travel ticket, less the value of the unused return ticket.

Terrorism Coverage

Patriot GoTravelSM
America
provides coverage for injuries and illness incurred as a result of an act of Terrorism, limited in amount and by circumstances. If an insured person is injured as a result of an act of Terrorism, and the insured person has no direct or indirect participation in the act, the plan reimburses eligible medical claims subject to a $50,000 lifetime maximum. Terrorism includes criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provide a state of terror in the general public or in a group of persons or particular persons, intimidate a population, or compel a government of international organization to do or to abstain from doing an act. However, this benefit does not cover an act of Terrorism in any country or location where the United States government has issued a travel advisory that has been in effect within the six months prior to the insured person’s date of arrival. In addition, claims incurred as a result of radiological, nuclear, chemical or biological weapons or events are not covered.

This benefit also does not cover an act of Terrorism in the event that an advisory to leave a certain country or location is issued by the United States government after the insured person’s arrival date, and the insured person unreasonably fails or refuses to heed such warning or depart the country or location.

Identity Theft Assistance

If an imposter obtains key personal information such as a Social Security or Driver’s License number, or other method of identifying an insured person in order to impersonate or obtain credit, merchandise or services in the insured person’s name, the Patriot GoTravel plans provide coverage up to $500 for the reasonable, customary and necessary costs incurred by the insured for: re-filing a loan or other credit application that is rejected solely as a result of the stolen identity event; notarization of legal documents, long dis-tance telephone calls, and postage that has resulted solely as a result of reporting, amending and/or rectifying records as a result of the stolen identity event; up to three credit reports obtained within one year of the insured person’s knowledge of the stolen identity event; and stop payment orders placed on missing or unauthorized checks as a result of the stolen identity event.

The identity theft event must occur during the Period of Coverage.

Description of Optional Riders

Adventure Sports Rider

The Adventure Sports Rider is available on Patriot GoTravelSM
America
for those up to the age of 65. The following activities are covered to the lifetime maximum amounts listed on page four as long as they are engaged solely for leisure, recreation, or entertain-ment purposes: abseiling, BMX, bobsledding, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, hot air ballooning, inline skating, jet skiing, jungle zip lining, kayaking, mountain biking, parachuting, paragliding, parascending, piloting a non-commercial aircraft, rappelling, rock climbing or mountaineering (ropes and guides to 4500m from ground level), scuba diving (to 50m), skydiving, snorkeling, snowboarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), wildlife safaris, and windsurfing. All such activities must be carried out in strict accordance with the rules, regulations and guidelines of the applicable Governing Body or Authority of each such activity. Certain sports activities are never covered, regardless of whether or not you purchase the Adventure Sports Rider. Please see page 14, exclusion 8. Please note this is only a summary of Adventure Sports and exclusions. For additional information, please refer to the Certificate of Insurance.

Enhanced AD&D Rider

This optional coverage is available for the primary insured person only. This coverage is in addition to the Accidental Death and Dismemberment already included in Patriot GoTravelSM
America
.This rider is available with a minimum purchase of three months of medical and AD&D rider coverage.

Citizenship Return Rider

When purchased at the time of application, the Citizenship Return Rider provides temporary medical coverage for non-U.S. citizens returning to their country of citizenship. For U.S. citizens, the rider provides up to 60 days of coverage for brief returns to the U.S. provided you have a current health plan in force and have resided outside the U.S. continuously for the past six months. Coverage for sudden recurrence of pre-existing conditions is excluded if the rider is selected. For premium information, please see the back of the Application Form.

Exclusions

Charges for certain services, treatments and/or conditions, among others, are excluded from coverage under the Patriot GoTravel plans and include but are not limited to:

A Pre-existing Condition which is any injury, illness, sickness, disease, or other physical, medical, mental or nervous condition, disorder or ailment that, with reasonable medical certainty, existed at the time of application or at any time during the three years prior to the effective date of the insurance, whether or not previously manifested or symptomatic, diag-nosed, treated, or disclosed prior to the effective date, includ-ing any subsequent, chronic or recurring complications or consequences related thereto or arising therefrom, whether or not previously manifested or known, diagnosed, treated, or disclosed.

Treatment or surgeries which are elective, investigational,experimental or for research purposes.

War, military action, terrorism, political insurrection, protest, or any act thereof.

Immunizations and routine physical exams.

Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the Certificate of Insurance.

Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome, or AIDS, and the cost of testing for these conditions, and charges for treatment or surgeries which are incurred by any Insured who was HIV+ at time of enrollment into this insurance.

Charges, injuries and/or illnesses resulting or arising from or occurring during the commission or continuing perpetration of a violation of law by the insured, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.

Injury and/or illness resulting or arising from being under the influence of alcohol or drugs; and injury or illness resulting from operating any type of vehicle after consuming any alcohol or drugs.

Willful self-inflicted injury or illness.

Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.

Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.

Treatment for mental and nervous disorders.

Organ or tissue transplants or related services.

Illness or injury where the trip to the host country is undertaken for treatment or advice for such illness or injury, except as expressly provided for in the certificate of insurance.

Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).

Any infection of the urinary tract (or Illness arising therefrom), that occurs within ninety (90) days of the Effective Date of coverage and that requires Treatment of the Insured Person in a Hospital; provided that any such Illness will be deemed by the Company to be a Pre-existing Condition. See "Sudden and Unexpected Recurrence of a Pre-existing Condition".

This brochure contains only a brief summary of current Patriot GoTravel benefits, conditions, limitations and exclusions, and is subject to all the terms and conditions of the full Certificate of Insurance. The complete Certificate of Insurance with all terms, conditions and exclusions will be included in the fulfillment kit sent to approved applicants. The Patriot GoTravel plans are amended, modified or replaced from time to time, and the administrator reserves the right to issue the most current Certificate of Insurance for this insurance plan in the event this application and/or brochure has expired, is modified, or is replaced with a newer version. Samples of current Certificate wordings are available upon request.

IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA): This insurance is not subject to, and does not provide benefits required by, PPACA. On January 1, 2014, PPACA will require U.S. citizens and certain U.S. residents to obtain PPACA compliant insurance coverage unless they are exempt from PPACA. Penalties may be imposed on U.S. citizens and U.S. residents who are required to maintain PPACA compliant coverage but do not do so. Please note that it is solely your responsibility to determine if PPACA is applicable to you.

Additional Benefits & Services

Locating a Provider

With Patriot GoTravelSM
America
, you may seek treatment with the hospital or doctor of your choice. When seeking treatment in the U.S., you can reduce your out-of-pocket costs by using the independent Preferred Provider Organization (PPO), a separately organized network of hundreds of thousands of established, highly qualified health care physicians and many well-recognized hospitals in the U.S. You can quickly search the network. Additionally, to help you locate health care providers out-side the U.S., the administrator provides its online International Provider AccessSM (IPA), a database of over 17,000 providers.

Universal Rx Pharmacy Discount Savings

This is a discount savings program available to every certificate holder of Patriot GoTravelSM
America
. This program allows card members to purchase prescriptions at one of over 35,000 participating pharmacies in the U.S. and receive the lower of 1) Universal Rx contract price or 2) the pharmacy regular retail price.

This discount program is not insurance coverage. It is purely a discount program to purchasers of the Patriot GoTravel plans. Use of the discount card does not guarantee that prescribed medication is covered under the insurance benefit plan.

Akeso Care Management® (ACM®)

The ability to access quality health care is of paramount importance when a medical emergency arises abroad. To coordinate care and provide U.S. and internationally based medical management services, the administrator formed ACM, an on-site specialized division devoted entirely to medical management.

The clinical staff consists of qualified physicians and registered nurses who are experts at assessing the need for services and ensuring those services are delivered in a timely, cost-effective manner. ACM has international medical experience, providing services in more than 170 countries worldwide.

ACM is accredited by URAC, an independent, nonprofit organization that is internationally recognized for promoting continuous improvement in the quality and efficiency of health care management. Through a rigorous and comprehensive review that ensures ongoing compliance, ACM earned its URAC accredita-tion in Health Utilization Management.

From routine medical care to complex case management, from check-ups to emergency medical evacuations, ACM is there for you. They are committed to consumer protection and empowerment, quality operations and regulatory compliance. This translates into better care for you - around the world, around the clock.

Administrator

Underwriter

Coverage is underwritten and issued by Sirius International Insurance Corporation, rated A (excellent) by A.M. Best and A- by Standard & Poor's (at the time of printing).

These Patriot GoTravel Medical Insurance plans are surplus lines products issued and underwritten by Sirius International Insurance Corporation (publ). Sirius International is rated A (excellent) by A.M. Best and A- by Standard & Poor’s (ratings are accurate as of the date of publishing and are subject to change). Sirius International is a White Mountains Insurance Group, Ltd company.